Speaker 1: Hello. My name is Aaron, and I'm here too talk
Speaker 1: about my tonsalectomy experience. So this happened when I was
Speaker 1: thirty five years old. It started, I guess in my
Speaker 1: early thirties. I was getting pretty consistently, I would say,
Speaker 1: two to three times a year some sort of tonsil
Speaker 1: infection where I would have to be on a two
Speaker 1: or three week course of antibiotics to clear it up.
Speaker 1: And this was really doing a number on well, my
Speaker 1: gut health for one, and just my health in general.
Speaker 1: This was kind of taking place right after COVID had started,
Speaker 1: and with these infections came a lot of fevers and
Speaker 1: just being run down and ill, which kind of resulted
Speaker 1: in me missing a lot of work because we weren't
Speaker 1: one hundred percent sure if it was COVID or not.
Speaker 1: It never was, but I just had to keep going
Speaker 1: in for these infections over and over, and finally my
Speaker 1: doctor said, this is too many antibiotics. Have you considered
Speaker 1: having your tonsils take it out? Because this is probably
Speaker 1: just going to keep happening. And I thought about it
Speaker 1: and my coworker, her son, who I don't remember how
Speaker 1: old he was, maybe eight or nine, had just had
Speaker 1: his tonsils out and he was fine. Two days later
Speaker 1: he was back at school. So I thought, well, this
Speaker 1: can't be that bad. Kids do it all the time.
Speaker 1: And I asked my doctor, you know, how long would
Speaker 1: I be out of work, and he said probably two
Speaker 1: to three days. So I put in for two to
Speaker 1: three days and scheduled the procedure. So I went in.
Speaker 1: Everything I guess went really well. My husband was there
Speaker 1: when I woke up. I don't really remember this, but
Speaker 1: I guess when I woke up, I was trying to yell,
Speaker 1: so they actually had to come in and re sedate
Speaker 1: me because I was coughing so much. So I spent
Speaker 1: an extra few hours in the recover room waking up,
Speaker 1: and the doctor came in, you know, and he told
Speaker 1: my husband everything went fine, gave him the prescriptions and said, unprompted,
Speaker 1: he said she'll be back to eating hard tacos in
Speaker 1: a few days, which was kind of you know. I
Speaker 1: wasn't awake for it, I don't remember. And so we
Speaker 1: went home, and you know, as the medications kind of
Speaker 1: wore off, my husband went and picked up. They gave
Speaker 1: me a codeine elixir, and I vividly remember for the
Speaker 1: next night and the night after that, sitting kind of
Speaker 1: propped up in bed, psyching myself up for half an
Speaker 1: hour to swallow my own spit because it hurt so badly.
Speaker 1: I this is gross. I kind of decided it wasn't
Speaker 1: worth it at some point and just started spitting it out.
Speaker 1: And this, as you can imagine, kind of created a
Speaker 1: problem for one staying hydrated and to actually getting my
Speaker 1: pain medication down. Even though it was a syrup, I
Speaker 1: just even just to swallow a sip of water was
Speaker 1: pretty agonizing.
Speaker 2: So after a couple.
Speaker 1: Of days of this, I was very, very run down,
Speaker 1: and I had started coughing up this awful brown gunk,
Speaker 1: and so I don't remember it was maybe around midnight.
Speaker 1: My husband ended up taking me to the emergency room,
Speaker 1: and I guessed when I got there, they said the
Speaker 1: gunk was to be expected, which I was not warned about,
Speaker 1: but I was also severely dehydrated, so they had to
Speaker 1: give me a couple bags of fluid, and they said
Speaker 1: that codine is not going to cut it, and I
Speaker 1: think they gave me hydrocodone, which was also a problem
Speaker 1: because those are huge pills. So for the next couple
Speaker 1: of weeks I did not go back to work. Because
Speaker 1: I couldn't really drink anything, I couldn't eat anything except jello,
Speaker 1: and eventually putting just a couple of bites every day.
Speaker 1: I was kind of getting by on pedia light. Just
Speaker 1: felt terrible. It was obviously I don't know what this
Speaker 1: feels like, but it kind of felt like swallowing razor blades,
Speaker 1: and so, you know, eventually it did get better, but
Speaker 1: I think when I looked back, even three or four
Speaker 1: months later, I still was pretty sore.
Speaker 2: And all this is.
Speaker 1: You know, I don't want to say don't get a
Speaker 1: tonsil ectomy. If you need one, you definitely should, but
Speaker 1: you know, I wish my doctor had been a lot
Speaker 1: more upfront with me about how terrible it was going
Speaker 1: to be. But on the plus side, I obviously haven't
Speaker 1: had a tonsil infection since because I don't have tonsils anymore.
Speaker 1: And I actually just had my first sore throat since
Speaker 1: the procedure a couple months ago, which is kind of exciting.
Speaker 1: I'm not on antibiotics all the time anymore, which is
Speaker 1: great and one of the things that kind of stuck
Speaker 1: with me. I talked to my grandmother, who had been
Speaker 1: a nurse for decades after I was done with a
Speaker 1: procedure about what had happened, and she said, I didn't
Speaker 1: want to tell you before you had this done. But
Speaker 1: the only thing I've heard it compared to pain wise
Speaker 1: is like an adult circumcision. And I kind of thought, why,
Speaker 1: I wish you had told me that to be better prepared.
Speaker 1: And also I ended up going into nursing afterwards, and
Speaker 1: I would tell nurses, you know, I had this ton
Speaker 1: selectomy in my thirties, and they would just get this
Speaker 1: look like why would you do that? So yeah, all
Speaker 1: that to say is I wish they had been more
Speaker 1: upfront about how terrible it was. But I am also
Speaker 1: glad that I did it.
Speaker 3: Aaron, great name, great name, great story, great story.
Speaker 2: Horrible story, horrible story.
Speaker 3: I had no idea how bad adult tonsle ectomies could be.
Speaker 2: I oo, it sounds just awful, awful, awful. I'm so sorry.
Speaker 3: Yeah, but also thank you for sharing your story.
Speaker 2: Thank you so much. Hi. I'm Aaron Welsh and I'm
Speaker 2: Eron Ollman Updyke.
Speaker 3: And this is this podcast will kill you Today we're
Speaker 3: talking all about tonsils. I mean kind of an off
Speaker 3: the wall topic, a little.
Speaker 2: Bit off the pharyngeal wall of.
Speaker 3: I don't know why it might have been prompted. I
Speaker 3: can't remember if I got a tonsilstone before or after
Speaker 3: or I suggested this. I think it was after, which
Speaker 3: is I conjured it?
Speaker 2: You really did? You suggested tonsils and I was like what,
Speaker 2: And then immediately it was like, yeah, do it. I
Speaker 2: have no idea how this is going to go or
Speaker 2: what we're going to talk about, but like, why not tonsils?
Speaker 3: I mean, I feel like tonsils occupy this weird space
Speaker 3: in like cultural history.
Speaker 2: Oh I thought you were going to say, like in
Speaker 2: your orofarings. Oh, well, that's true. It's gonna be all episode.
Speaker 3: Like I remember as a kid wanting to have my
Speaker 3: tonsils taken out so that I could miss school and
Speaker 3: eat ice cream. Like that's what I thought.
Speaker 2: It was. Oh my god. Okay, So when I told
Speaker 2: my parents that we were going to be doing tonsils,
Speaker 2: it's been hilarious to tell people that were doing this episode.
Speaker 2: My mom was like, oh, I still have mine, but
Speaker 2: a lot of people don't, like a lot of people
Speaker 2: my age. And then she turns to my dad and
Speaker 2: she goes, do you still have your tonsils? And yeah,
Speaker 2: I got mine, but everyone wanted to get theirs out
Speaker 2: and I was like what, and he goes, well, you
Speaker 2: got ice cream? Where did this?
Speaker 3: Where did this? Notion?
Speaker 2: It?
Speaker 3: Like dug in so deeply I distinctly remember. And I
Speaker 3: don't even know if I knew anyone growing up. John
Speaker 3: my fiance has his tonsils gone. And I think also.
Speaker 2: In Madeline, was it her tonsils or her appendix? Her appendix? Yeah,
Speaker 2: so it wasn't that. Then I don't know.
Speaker 3: I mean, actually I do know, because I the history
Speaker 3: section will reveal all.
Speaker 2: Oh okay, I.
Speaker 3: Can't wait, which doesn't usually happen. And maybe it doesn't
Speaker 3: reveal all, but I do feel like it answered a
Speaker 3: lot of my own personal questions about like why were
Speaker 3: ton selectamies, why do we know them by name? Why
Speaker 3: didn't everyone seem to have a tons electomy? And like
Speaker 3: most of the twentieth century.
Speaker 2: Ooh, I can't wait to hear all about it. But first,
Speaker 2: but first, it's quarantiny time.
Speaker 3: It certainly is, Thank goodness, what are we drinking this week?
Speaker 2: In the spirit of Ton selectamees, we're drinking the Cutthroat.
Speaker 3: Not just a trout, but also a delicious cocktail recipe.
Speaker 3: What is what is in the Cutthroat.
Speaker 2: It is a malted chocolate milk beverage that'll make sense later,
Speaker 2: I promise, with malted milk powder and vanilla ice cream,
Speaker 2: chocolate sauce, some whiskey in there. Oh, it's just fantastic.
Speaker 3: Honestly, so perfect. Had to have the ice cream in
Speaker 3: there too, like of course. But we will post the
Speaker 3: full recipe for the Cutthroat, Quarantiney and the non alcoholic
Speaker 3: place Rita on our website. This podcast will kill You
Speaker 3: dot com and all of our social media channels.
Speaker 2: Our website, This podcast will kill you dot Com. It's
Speaker 2: a pretty incredib website if you haven't been there yet
Speaker 2: and check it out. We've got transcripts from all of
Speaker 2: our episodes. We've got sources from this episode and every
Speaker 2: one of our episodes. We've got links to blood Mobile
Speaker 2: for music. We've got our good Reads account, our oh
Speaker 2: I'm flailing here, We've got Patreon, We've got us there's
Speaker 2: check it out.
Speaker 3: You're good, You're good, We got it merge.
Speaker 2: Okay, are we ready for the biology?
Speaker 3: Let's do it right after this break?
Speaker 2: Okay, Tonsils, Tonsils, And now I that I had written
Speaker 2: something really clever to start this off with. But I didn't.
Speaker 2: I mean, tonsils don't rhyme with like anything. I know
Speaker 2: you sent me that screenshot of all the things they
Speaker 2: ninety two percent rhyme with.
Speaker 3: Right, It's terrible. Console was the closest.
Speaker 2: It's not even good. So first of all, what most
Speaker 2: of us think of when we think of our tonsils
Speaker 2: are in fact only one of four different tonsils in
Speaker 2: our bods.
Speaker 3: Yeah, that was like one of the first things I learned,
Speaker 3: and I was felt like I had been lied to
Speaker 3: my whole life, But really I just didn't seek the knowledge.
Speaker 2: So the set of two tonsils, it's a paired set
Speaker 2: of tonsils that sit at the back of our throat,
Speaker 2: the ones that get swollen when we get strep throat
Speaker 2: or any other infection. Those are called our palatine tonsils.
Speaker 2: But we have three more. We have tonsils at the
Speaker 2: very base of our tongue, like where our tongue connects
Speaker 2: back in the base that are appropriately named our lingual tonsils.
Speaker 2: We have a set that's like in the wall of
Speaker 2: our naso pharynx, way back up near the opening to
Speaker 2: our eustachian tubes. That's our ear tubes. And those are
Speaker 2: called our tubal tonsils. They're little. And then we have
Speaker 2: another one that sits at the top rear of our palette,
Speaker 2: in our naso pharynx like above and behind our soft palate,
Speaker 2: right in the midline where our nose kind of connects
Speaker 2: to the back of our throat. And this particular tonsole,
Speaker 2: which is called our phyngeal tonsil, is also called our adenoid.
Speaker 3: Ah okay, so.
Speaker 2: When you hear adenoids and tonsiles, those are the same things.
Speaker 2: They're just talking about two different sets of tonsoles. And
Speaker 2: everyone always says adenoids, but it's just one, like it's
Speaker 2: one structure. It's not a paired it's a one.
Speaker 3: I mean, it's like JC Pennies or Myers.
Speaker 2: Or sorry you say J C. Pennies plural.
Speaker 3: I have heard people say that. I do say Myers.
Speaker 2: What is Myers?
Speaker 3: Remember Meyer the grocery store chain?
Speaker 2: Oh yeah, yeah, yeah, yeah, I forgot about that, yeah,
Speaker 2: showing our Midwest. Yeah. Anyways, anyways, our adenoids and our tonsils,
Speaker 2: meaning our phyngeal tonsil and our palatine tonsils, are the
Speaker 2: two that we all think of the most when we
Speaker 2: think of our tonsils, because these are the ones that
Speaker 2: get big and swollen and oftentimes painful when we get
Speaker 2: an infection. So these are the two that we'll focus
Speaker 2: on kind of. But really, when I'm talking about tonsils,
Speaker 2: it means all of these different things. So what are
Speaker 2: these things anyway? Like, what the heck are tonsils and what.
Speaker 3: Do they have in common with one another?
Speaker 2: Well, let me tell you. All of these tonsils are
Speaker 2: a type of tissue that are called mucosal associated lymphoid
Speaker 2: tissue or MALT.
Speaker 3: Oh yeah, okay.
Speaker 2: All of these tonsils together form a ring at the
Speaker 2: back of our throat, which is essentially at the opening
Speaker 2: of both our digestive and our respiratory systems. Right, and
Speaker 2: this ring is sometimes called wall Dyer's ring, probably named
Speaker 2: after a guy, I'm sure. But the function of all
Speaker 2: of these tissues, all of this ring of tonsilar tissue,
Speaker 2: essentially is in short, to protect us against infection. The end,
Speaker 2: our tonsils are part of our immune system.
Speaker 3: But it's like the type of tissue, so that type
Speaker 3: of tissue is like only found in these tonsils.
Speaker 2: Oh, great question. No, tonsils are by no means the
Speaker 2: only form of MALT mucosal associated lymphoid tissue that exist
Speaker 2: In fact, they are a small part of a large
Speaker 2: network of malt throughout our bodies. Basically all of malt
Speaker 2: are these immune related tissues that exist specifically on our
Speaker 2: mucosal surfaces in our guts. We often call this galt
Speaker 2: gut associated lymphoid tissue. So we have gut tonsils, yeah,
Speaker 2: pretty much. They're called Pyre's patches in our guts. We
Speaker 2: also have like isolated lymphoid follicles that just kind of
Speaker 2: scatter throughout our guts and we have wait for it,
Speaker 2: an appendix, also lymphoid tissue. There's also bronchial malt, which
Speaker 2: is sometimes called BLT, although not all humans have this.
Speaker 2: I don't know. It's probably really interesting. I didn't get
Speaker 2: into it. What rodents don't have tonsils, but they do
Speaker 2: have not which is masofyringeal associated lymphoid tissue.
Speaker 3: This is why spoilers. I didn't get into the evolutionary
Speaker 3: history of tonsils. Is because I got really overwhelmed by
Speaker 3: nalt and malt and disseminated malt and like organized or
Speaker 3: something malt.
Speaker 2: And nalt and I was too much. This sounds very cool.
Speaker 3: Yeah, this is over my head and I'm gonna focus
Speaker 3: on other things.
Speaker 2: Well, let me bring it under your head again, because
Speaker 2: is that appropriate?
Speaker 3: Sure? I love it.
Speaker 2: So the question that we want to understand is, like
Speaker 2: these globs of tissue that are associated with our immune system,
Speaker 2: like what does that actually mean? Like what does it
Speaker 2: even mean to be a part of our immune system?
Speaker 2: What are they doing? What are they composed of? If
Speaker 2: we remember, way, way way back to our Vaccines episode
Speaker 2: season two, I know, major throwback. Yeah, In that episode,
Speaker 2: we talked about the very specifics of the ways that
Speaker 2: our immune system responds to antigens, basically responds to the
Speaker 2: stuff viruses, bacteria, dust, proteins, the crud that we're exposed
Speaker 2: to all the time. And I won't make you go
Speaker 2: back and listen to that, but if anyone wants to,
Speaker 2: it's a great episode. But I'll summarize what we talked
Speaker 2: about really briefly so that we can understand tonsils. In
Speaker 2: that episode, I split the immune system into a four
Speaker 2: act play focusing specifically on our adaptive immune system. The
Speaker 2: summary is basically that our bodies, mostly via things like
Speaker 2: our nose and our mouth, but also our guts and
Speaker 2: our skin and our eyes, are constantly exposed to hundreds
Speaker 2: of thousands of stuff every day, and we call this
Speaker 2: stuff antigens, and our immune system's job is to identify
Speaker 2: all of this stuff and decide what belongs and what doesn't,
Speaker 2: what's a part of us, and what is not supposed
Speaker 2: to be there, and how to deal with it. And
Speaker 2: one of the major ways that we do this is
Speaker 2: that we have cells in our body called macrophages. These
Speaker 2: cells go along in either our bloodstream or our lymphatics
Speaker 2: and they gobble up this crud, these antigens wherever they're
Speaker 2: exposed to them and bring them to our T cells,
Speaker 2: who then bring that crud to our lymph nodes, which
Speaker 2: we also touched on in our Lymphatic Philrise this episode,
Speaker 2: and lymph nodes is where our B cells hang out,
Speaker 2: and our B cells are what make antibodies that will
Speaker 2: then be very specific to be able to find, neutralize,
Speaker 2: and destroy the crud the anigens. It turns out that
Speaker 2: that part is accurate, but leaves out part of the
Speaker 2: story of our immune system, and that story is is malt.
Speaker 3: So malt it sounds like you're talking about a person.
Speaker 2: It just makes me think of malted milk. I mean
Speaker 2: appropiate appropriate, Okay, so malt, the composition of malt tissue
Speaker 2: is very similar to our lymph nodes themselves, except that
Speaker 2: it is not connected to our lymphatic system.
Speaker 3: That is so bizarre.
Speaker 2: And mm hmm it gets cooler because the stuff that
Speaker 2: MALT is sampling, the stuff that it's going to decide
Speaker 2: whether or not for our B cells to mount a
Speaker 2: response to, is being sampled directly from the mucosa itself,
Speaker 2: rather than going through macrophages, traveling through the lymphatics and
Speaker 2: then making its way to the lymph nodes. So it's
Speaker 2: like first line exactly. It is first line. That is
Speaker 2: what malt is. It is first line immune system.
Speaker 3: Okay, now I kind of wish I had read more
Speaker 3: about the evlcary history because I wonder how basal that
Speaker 3: is compared to other parts of our immune system.
Speaker 2: Anyway, it would be really interesting. Histologically, malt is very
Speaker 2: similar to lymph nodes, except that it doesn't tend to
Speaker 2: have a capsule, and again they don't have any lymphatic drainage.
Speaker 2: But the outer cells of malt tissue, including our tonsils,
Speaker 2: have these cells called m cells, which are depending on
Speaker 2: the source, called membrane cells or microfold cells. But These
Speaker 2: are cells that are essentially just really good at uptaking
Speaker 2: the stuff that our mucosa, our nose, our mouth, our
Speaker 2: guts are constantly exposed to floating across our mucosa. These
Speaker 2: M cells take them up and then shuttle them into
Speaker 2: the core of these tonsils or other malt tissue, but
Speaker 2: we'll focus on tonsils for this episode. Our tonsils have
Speaker 2: these crypts, these like deep crypts, and so these structures
Speaker 2: are covered with this epithelial tissue, and then these M
Speaker 2: cells just like swoop stuff into the inner bits where
Speaker 2: are housed B cells and T cells. And these B
Speaker 2: and T cells do exactly what they do everywhere else
Speaker 2: in our body. They sample anigens and then they make antibodies.
Speaker 2: And it gets even cooler because I can see your
Speaker 2: face being like, what questions. Yeah. Absolutely, our malt tissues,
Speaker 2: especially our tonsiles and our pyres patches in our gut,
Speaker 2: they make and secrete a kind of specialized type of
Speaker 2: antibody called IgA, which is different than other antibodies like
Speaker 2: IgM and IgG. And it's probably beyond the scope of
Speaker 2: this episode to get into the nitty gritty on all
Speaker 2: these different types of antibodies, but IgA is a really
Speaker 2: important type of antibody that really does function as a
Speaker 2: first line defense on these mucosal surfaces, and it's being
Speaker 2: secreted from things like our tonsils and adenoids and in
Speaker 2: our guts and things like that.
Speaker 3: This okay, I don't even know where to begin. I'm fascinated.
Speaker 3: I don't even know if I have a question at
Speaker 3: the end of this. I mostly just want to say, how, yes,
Speaker 3: we should definitely do an episode on all the igs.
Speaker 3: And secondly, it's just beautiful.
Speaker 2: It really is. It really is. Wow. Okay.
Speaker 3: No, And so what's the purpose of the crypts?
Speaker 2: They essentially are what are like funneling and shuttling things
Speaker 2: in if that makes sense, and kind of grabbing onto
Speaker 2: them a little bit. It's an increasing surface area for
Speaker 2: stuff to get slooped in. Yeah. Yeah. And our tons
Speaker 2: especially our palatine tonsils and are adenoid or fringial tonsules
Speaker 2: and the other ones as well. They are especially important
Speaker 2: in this role because they form this ring around the
Speaker 2: entrance to two of our most important systems that interact
Speaker 2: with the outside world, our digestive system and our respiratory system. Yeah.
Speaker 2: So our tonsils are being constantly exposed to everything all
Speaker 2: the time. So that's what they do, that's what they're for.
Speaker 2: They are a hugely important part of the development of
Speaker 2: our antibody mediated immune response, especially for things like respiratory
Speaker 2: viruses and bacteria.
Speaker 3: You may have already said this, but which tonsils are
Speaker 3: the biggest.
Speaker 2: Great question. The ones that you think of as tonsils,
Speaker 2: your palatine tonsils, the two that sit in the back
Speaker 2: of your throat are the biggest. Okay, like physically they're
Speaker 2: the big honkers that you see. The tubular tonsils near
Speaker 2: ustation tubes are really quite small. You're adenoid up in
Speaker 2: your nasopharynks can get large and we'll talk about it,
Speaker 2: but is just a single tonsil and is a little
Speaker 2: smaller than the others. And then your lingual tonsils back
Speaker 2: in the back of your tongue are actually a whole
Speaker 2: series of a bunch of really little things, okay, like
Speaker 2: little little cell areas and nuggets. I'm doing things with
Speaker 2: my hands like patcheep, you can't see, yeah, yeah, patt,
Speaker 2: patchy bits.
Speaker 3: Okay, is now the time to say, well, what the heck?
Speaker 3: If they're so like they seem pretty dang cool and important,
Speaker 3: how can we take them out with seemingly few negative
Speaker 3: consequences are their negative consequences? Why do they get so
Speaker 3: bad that they have to be taken out? All of that?
Speaker 2: I know, Yeah, there's a lot of stuff. There was
Speaker 2: a lot where I was like, I don't know where
Speaker 2: to go for We're like, that's what a tonsil is,
Speaker 2: now what So let's start with where can things go wrong?
Speaker 2: If these are something that is so great, then why
Speaker 2: don't we talk about when things are less great? I e. Tonsilitis?
Speaker 2: Shall we?
Speaker 3: Yeah?
Speaker 2: So tonsilitis literally just means inflammation itis in your tonsils.
Speaker 2: And again, at this point, when I'm talking about tonsils,
Speaker 2: I am primarily now only talking about the two big ones,
Speaker 2: the phryngial tonsil that is your adenoids and primarily the
Speaker 2: palatine tonsils that are commonly referred to as tonsils. Right, So,
Speaker 2: tonsilitis turns out is not actually like a very specific
Speaker 2: thing because sore throat in general is really common. It's
Speaker 2: one of the most common symptoms. It's associated with so
Speaker 2: many viral infections, the flu, the common cold, covid mono,
Speaker 2: so many bacterial infections, strep throat, many more. Not all
Speaker 2: sore throats will necessarily cause inflammation in the tonsils themselves,
Speaker 2: and sometimes a sore throat is just called like acute pharyngitis,
Speaker 2: which just means sore throat in medical terms, inflammation in
Speaker 2: the pharynx or whatever. But often there is some degree
Speaker 2: of tonsilitis, especially depending on the age of the person
Speaker 2: and the infectious agent that happens when there is sore throat.
Speaker 2: There's a few different reasons why our palatine tonsils, the
Speaker 2: two in the back of your throat, are so very
Speaker 2: prone to this. Partly it's because, like I already said,
Speaker 2: they are constantly being exposed to and sampling all of
Speaker 2: the viruses and bacteria that we're exposed to, and that
Speaker 2: just like live and hang out in our throats.
Speaker 3: They're just like walking around Costco trying every single sample,
Speaker 3: not blocking the entrance to the aisles.
Speaker 2: Yes, that's what it is, because that's what happens. The
Speaker 2: crypts just get trapped. Sometimes stuff gets stuck in the
Speaker 2: aisles of Costco in our tonsils. I don't know if
Speaker 2: this metaphor is like, I love it.
Speaker 3: I love it.
Speaker 2: But then they can begin to proliferate before we've managed
Speaker 2: to mount a sufficient immune response, right, And that's going
Speaker 2: to cause some degree of blood flow inflammation to the area.
Speaker 2: Pain receptors cytokines are going to be sent out, which
Speaker 2: are going to tell us that there's pain. There's also
Speaker 2: I have a really interesting paper on like the actual
Speaker 2: path of physiology of the pain of a sore throat
Speaker 2: that's like really fascinating and interesting. But there's like a
Speaker 2: lot of open nerve endings that exist in that region,
Speaker 2: which is part of it.
Speaker 3: Like why it's so painful.
Speaker 2: It's so painful, I know. But anyways, on top of that,
Speaker 2: a lot of the respiratory pathogens that cause sore throat,
Speaker 2: especially like all of the millions of rhinovirus serovars, are
Speaker 2: really well adapted to the cells of our tonsils. So
Speaker 2: they are actually really good at not just being sampled by,
Speaker 2: but getting into and replicating within the cells of our tonsils.
Speaker 2: So our tonsils cells. While there's like this trade off, right,
Speaker 2: they're really good at sampling all of this material, but
Speaker 2: they're also really prone to infection because they sit at
Speaker 2: some of the most commonly infected sites in our upper airways.
Speaker 2: Right on top of that, the people who get the
Speaker 2: most infections in their tonsils and the most severe infections
Speaker 2: in their tonsils are kids, especially school age kids, And
Speaker 2: part of that is because our tonsils, which are present
Speaker 2: from birth, actually grow during early childhood and they reach
Speaker 2: their peak in size in kids' ages like four to eight,
Speaker 2: and then they start to regress as we get older. Interesting,
Speaker 2: on top of that, comparative to body size, the tonsils
Speaker 2: are the largest in very young kids. So rather than
Speaker 2: like school age and like teenage years, when the tonsils
Speaker 2: are still kind of growing when they're very young like
Speaker 2: three four, compared to the size of their throat, tonsils
Speaker 2: are really big, even though they're going to continue to grow.
Speaker 2: Does that make sense, Yeah?
Speaker 3: And then like the swelling then is exactly so much
Speaker 3: more pronounced.
Speaker 2: Yes. So that is where this type of inflammation can
Speaker 2: cause real problems. This infection and inflammation can either just
Speaker 2: be very recurrent, especially in like school aged kids from
Speaker 2: like five to fifteen. It can cause really recurrent infections
Speaker 2: which can end up with a lot of misschool or
Speaker 2: just a lot of pain, a lot of exposure to antibiotics.
Speaker 2: As we heard in our first hand account, which was
Speaker 2: not even during school age. This kind of hypertrophy can
Speaker 2: also put kids at increased risk of things like recurrent
Speaker 2: ear infections, because hypertrophy of various tonsular tissue can also
Speaker 2: then compress the Eustachian tubes where our ears are supposed
Speaker 2: to drain, which is what can increase the risk of
Speaker 2: your infections. And of course if tonsils and especially adenoids,
Speaker 2: which sit at the top back of our nasopharynks, become
Speaker 2: severely enlarged and hypertrophied, it can cause problems with breathing,
Speaker 2: both in the acute form, where an acute infection can
Speaker 2: be a real risk of respiratory distress, or just over
Speaker 2: time it can cause obstructive sleep apnea in kids. There
Speaker 2: is also a phenomenon that you may have heard of
Speaker 2: called paratonsular abscess.
Speaker 3: You can across that I did not but absess in tonsils.
Speaker 2: Abscess in tonsils, and it's not really in tonsoles. Really,
Speaker 2: This is a complication that happens when an infection kind
Speaker 2: of spreads beyond the tonsils. It can also happen in
Speaker 2: absence of tonsils, even after a tonsilectomy, for example. But
Speaker 2: it's essentially just a group of deep space neck infections.
Speaker 2: So abscesses either right next to the tonsils or in
Speaker 2: the back of the tonsiles or in the retroferyngeal or
Speaker 2: parafheryngial space. Essentially, our neck is very complicated with a
Speaker 2: whole bunch of things in it in a really small
Speaker 2: amount of space. So we have a lot of like
Speaker 2: fascial layers separating these all, and if infection spreads beyond
Speaker 2: some of those fascial planes, it can become very severe
Speaker 2: and lead to airway compromise really easily.
Speaker 3: That makes sense.
Speaker 2: So these type of infections can be really serious because
Speaker 2: they can, you know, cause a lot of swelling and
Speaker 2: make it so that people can't breathe.
Speaker 3: And is this associated with certain pathogens or is it
Speaker 3: just like anything can do it?
Speaker 2: Anything can do it. Bacterial infections are going to be
Speaker 2: much more likely to cause an absess than anything like
Speaker 2: a viral infection and strep decocye like your group, A
Speaker 2: strip strip throat is a really common one, but by
Speaker 2: no means the only pathogen that can cause these types
Speaker 2: of infections. Okay, Yeah, and then there are tonsil stones.
Speaker 3: Yay, I'm so glad you're talking about these. I've had
Speaker 3: two in.
Speaker 2: My life, yeah, and one just recently.
Speaker 3: One recently and the other one was I was like
Speaker 3: a freshman in college or a sophomore in college.
Speaker 2: Tonsilstones are just collections of shmuts. Really, it's unsatisfying. I
Speaker 2: feel it's just shmuts that gets stuck in those little
Speaker 2: crypts in the tonsils. And what our body tends to
Speaker 2: do to shmuts anywhere in our body is kind of
Speaker 2: calcify it to be like, let's wall this off and
Speaker 2: package it up so that it doesn't cause any more problems,
Speaker 2: and in so doing it can sometimes cause problems.
Speaker 3: It's like cask of a mantiato style. Have I had
Speaker 3: that joke on this podcast before.
Speaker 2: I don't know, because I don't know what it means,
Speaker 2: because I'm probably not smart enough.
Speaker 3: No, it's like some Edgar Allan Poe story I think,
Speaker 3: where somebody like bricks in somebody else into a wall, and.
Speaker 2: I thought, isn't that the heart? The telltale heart thing
Speaker 2: that was different.
Speaker 3: One who killed someone? Wow, clearly we need to refresh
Speaker 3: our Poe.
Speaker 2: We're knowledge, We're not getting it. No anyways, tonsilstones shmuts
Speaker 2: in your tonsils. These can also happen in your salvary glands,
Speaker 2: like they can happen in a lot of other places.
Speaker 2: That's not that's all I really have for that. It's
Speaker 2: not all that exciting, But those are the kind of
Speaker 2: ways in which tonsils can become a problem and why
Speaker 2: someone might need to undergo a tonsilectomy and an adenoid ectomy.
Speaker 3: Are stones enough for that?
Speaker 2: No?
Speaker 3: No, no, Okay, So there are reasons to remove tonsils,
Speaker 3: but maybe not as much as people used to lean
Speaker 3: into in historical times. Yeah, but what happens when those
Speaker 3: tonsils are gone? Because it seems like from what my
Speaker 3: growing up interpretation or like what you know, my ingrained
Speaker 3: knowledge and also reading about this, is that there aren't
Speaker 3: many negative consequences.
Speaker 2: Yeah, so there's risks associated with surgery, right, Yeah, So
Speaker 2: most of the complications that we see are in that
Speaker 2: acute phase where you have risk of things like bleeding,
Speaker 2: You have risk of infection as a result of surgery.
Speaker 2: Bleeding is really the big one, and in really severe cases,
Speaker 2: people can end up dying as a result of complications
Speaker 2: from surgery. Very rare, but surgery is surgery, and so
Speaker 2: complications can happen beyond that surgical complication timeframe. We don't
Speaker 2: really have a lot of data to say that there
Speaker 2: are negative effects in the long term from not having tonsils,
Speaker 2: and when it's indicated, like in the case of really
Speaker 2: recurrent infections or even in the case of obstructive sleep
Speaker 2: apnea in young kids, there is some data that there
Speaker 2: is benefit to tonsil removal in those cases because it
Speaker 2: can significantly reduce the rate of recurrent infection, and in
Speaker 2: kids with obstructive sleep it can improve their sleep, even
Speaker 2: if it's only in the short term. And we'll get
Speaker 2: more into that later. But it's fascinating that something that
Speaker 2: would appear as integral as a major source of antibodies
Speaker 2: and a major source of sampling of our environment to
Speaker 2: protect against infection can be removed with relatively little consequence.
Speaker 2: To me, what I think makes that so fascinating is
Speaker 2: it kind of shows how many redundancies we have in
Speaker 2: our bodies.
Speaker 3: I was just about to say, it's like built in redundancy.
Speaker 2: Exactly, and it is right, because whenever tonsils are being removed,
Speaker 2: it's not all of them. You still have your lingual tonsils,
Speaker 2: you still have those tubul tonsils. Nobody's removing those. It's
Speaker 2: just the palatine tonsils and sometimes the adenoids, sometimes both,
Speaker 2: but sometimes just like one or the other. Right, So,
Speaker 2: first of all, we have redundancy just within that. There's
Speaker 2: also additional like malt like tissue throughout other parts of
Speaker 2: our mucosa that just isn't as well organized as the
Speaker 2: actual tonsils themselves. And then of course there's the rest
Speaker 2: of our entire immune system, which is doing all the
Speaker 2: same stuff, it's just doing it in a slightly different
Speaker 2: way than this mucosal lymphoid tissue is doing. So cool
Speaker 2: it is, and there's a lot more that we could
Speaker 2: do in talking about malt and galt because yeah, like Celiac,
Speaker 2: for example, is associated with discrepancies in gault and IgA
Speaker 2: secretion and things like that. Like it. It's really cool.
Speaker 3: Well that's on our list for sure, it is.
Speaker 2: So that's tonsils, Aaron.
Speaker 3: They're amazing.
Speaker 2: They're so cool except when they're a problem, and then
Speaker 2: it's cool that you can take them out. So tell me, Aaron,
Speaker 2: where did we get to hear from? Is that?
Speaker 3: Why don't I just share what I brought with me
Speaker 3: to share right after this break?
Speaker 2: Please?
Speaker 3: So it turns out that people have been irritated about
Speaker 3: tonsils or found them to be like troublesome enough to
Speaker 3: get rid of them. For millennia stop it.
Speaker 2: Oh yeah, I don't want a millennia to go anyone
Speaker 2: cutting anything out of me. I gotta be honest with you.
Speaker 2: I've listened to enough episodes of this podcast.
Speaker 3: I think that given some of the quotes that I'm
Speaker 3: going to toss and sprinkle in throughout here, you will
Speaker 3: that opinion will be even more reinforced.
Speaker 2: Yeah, okay, yeah, because this was like.
Speaker 3: Pre anesthesia, pre antibiotics. Nope, but I was honestly really
Speaker 3: take a back by the number of references to tonsilectomies
Speaker 3: over the centuries. Huh, they're everywhere.
Speaker 2: All right.
Speaker 3: So from one thousand BCE in a Hindu medicine textbook quote,
Speaker 3: when the phlem and blood are deranged in the soft
Speaker 3: palate and tonsils, they become large and like a full bladder,
Speaker 3: accompanied with thirst, cough, and difficulty in breathing. When troublesome,
Speaker 3: they are to be seized between the blades of a forceps,
Speaker 3: drawn forward and with a semicircular knife, the third of
Speaker 3: the swelled part is removed. If all be removed, so
Speaker 3: much blood may be discharged as will destroy the individual.
Speaker 3: If too little is removed, it will produce an increase
Speaker 3: in the swelling with fainting and swimming of head end quote.
Speaker 4: Oh my goodness, Yeah, I can picture every piece of
Speaker 4: that that you just described, like very clearly, and I
Speaker 4: don't like it.
Speaker 3: Oh okay, if you didn't like this one, you're really
Speaker 3: not gonna like this next.
Speaker 2: Give it to me.
Speaker 3: Okay. So this is from Celsus, a Roman aristocrat who
Speaker 3: lived from like twenty five BCE to fiftycee. Quote. They
Speaker 3: ought to be disengaged all round by the finger and removed.
Speaker 3: What if they are not separated by this method, it
Speaker 3: is necessary to take them up with a blunt hook
Speaker 3: and separate them with a scalpel, then to wash them
Speaker 3: with vinegar and anoint the wound with a stiptic application.
Speaker 2: Can you just imagine how much that would hurt? Because
Speaker 2: you're talking about an acutely inflamed, angry organ and using
Speaker 2: a fingernail.
Speaker 3: I I really feel like this.
Speaker 2: Quote, as the kids say, has like.
Speaker 3: Rent free in my head since reading it, I just
Speaker 3: keep I have this intrusive thought of like a fingernail
Speaker 3: and the tonsils. I'm sorry, I know, but the way
Speaker 3: that both of these descriptions are written kind of sounds
Speaker 3: like this is a relatively common procedure. Yeah, and that's
Speaker 3: supported by the many, many more quotes that I'm going
Speaker 3: to toss in here. So, for instance, in the second
Speaker 3: century CE, Galen wrote about using a snare to amputate
Speaker 3: the tonsil, and this method increased in popularity over the centuries,
Speaker 3: with a few authors advocating for like, hey, let's remove
Speaker 3: just part of it and not all of it so
Speaker 3: that we don't cause hemorrhage.
Speaker 2: Yeah, good call. Yeah.
Speaker 3: The next quote I think provides an excellent glimpse into
Speaker 3: the world of pre modern day surgery. From the fourth
Speaker 3: century CE, Greek physician Paul of a Gina wrote quote,
Speaker 3: when therefore they are in flame, we must not meddle
Speaker 3: with them, But when the inflammation is considerably abated, we
Speaker 3: may operate more, especially upon such as are white contracted
Speaker 3: and have a narrow base. But those which are spongy
Speaker 3: red and have a broad base are apt to bleed. Therefore,
Speaker 3: seating the person in the light of the sun and
Speaker 3: directing him to open his mouth, while one assistant holds
Speaker 3: his hand and another presses down the tongue with a
Speaker 3: wooden spachela, we take a hook and perforate the tonsil
Speaker 3: with it and drag it outwards as much as we
Speaker 3: can without drawing its membranes along with it, and then
Speaker 3: we cut it out by the root with a scalpel
Speaker 3: suited to that hand. After ligation, the patient must gargle
Speaker 3: with cold water or oxycrate, which is a mixture of
Speaker 3: water and vinegar, or if hemorrhage occurs, he may use
Speaker 3: a tepid decoction of brambles, roses, or myrtle leaves.
Speaker 2: End quote. That's very detailed.
Speaker 3: I think the thing that stuck out to me the
Speaker 3: most with that was that make sure that they're like
Speaker 3: it's the noonday sun and that the light is penetrating
Speaker 3: the back of their throat. I just didn't think of that.
Speaker 2: Also, someone is holding their hand. Yeah.
Speaker 3: So, during the Middle Ages, tonsile ectomies went through a
Speaker 3: decline in popularity like many other surgeries, and swollen or
Speaker 3: absessed tonsiles were mostly dealt with through just like lancing
Speaker 3: the tonsil rather than straight up removal. But you know
Speaker 3: how trends come and go. Yeah, I'm thinking about buying
Speaker 3: flare jeans, which I never thought I would do again
Speaker 3: after high school. You know, gotta be cool and by
Speaker 3: the sixteenth century or so, people were starting to get
Speaker 3: back into removal. Ambros Pare a very famous French surgeon
Speaker 3: and anatomist.
Speaker 2: He was one of the.
Speaker 3: Major ones to kickstart surgery and also work on like
Speaker 3: surgical improvements during this period. He was a big proponent
Speaker 3: of gradually strangling the tonsil with a ligature until circulation
Speaker 3: was cut off, which just like sounds deeply unpleasant.
Speaker 2: I mean, at least you'd bleed a lot less.
Speaker 3: I mean, yeah, yeah, But I think that this, like
Speaker 3: this next quote speaks to some of the discomfort. So
Speaker 3: someone from this era wrote that this method of tonsil
Speaker 3: ectomy quote is liable to resolve itself into physical combat
Speaker 3: between the surgeon and his patient end quote. Oh I
Speaker 3: mean yeah, yeah. I feel like it's not even like
Speaker 3: you're not you just it's like instinctive, like you just
Speaker 3: you're going to fight it out of my mouth exactly.
Speaker 3: Other surgeons of the time objected to the procedure because
Speaker 3: of what was thought about the purpose and physiology of tomnsils,
Speaker 3: which was that essentially they absorbed the secretions that came
Speaker 3: from the brain and then exited through the nasal cavity,
Speaker 3: and then the tonsils like sent them back to the
Speaker 3: brain after filtering something like that.
Speaker 2: Wow, that is complicated.
Speaker 3: Right, and so with the tonsils gone, those secretions would
Speaker 3: just linger and cause hoarseness. So it turns out that
Speaker 3: the controversy around removing tonsils is nearly as old as
Speaker 3: the procedure itself. So, for instance, take this quote by
Speaker 3: Dionus from sixteen seventy two. Quote, some of our ancestors
Speaker 3: proposed the separation and evulsion of these glands, which operation
Speaker 3: they very easily performed. I refer you the methods which
Speaker 3: they proposed to do it, which I think very cruel,
Speaker 3: for the function these glands being to separate and filtrate
Speaker 3: the sacroites which serve to moisten the tongue, larynx, and esophagus.
Speaker 3: These parts must find themselves deprived of that do which
Speaker 3: is of great use in tempering of the air and
Speaker 3: the lungs and slighting the nourishment into the stomach. Okay, yeah,
Speaker 3: and so on this theme of controversy. I found this
Speaker 3: quote in many of the other quotes that I've mentioned
Speaker 3: so far, in a paper titled quote a History of
Speaker 3: Tonsilectomy to Millennia of Trauma Hemorrhage and controversy.
Speaker 2: Ooh end quote.
Speaker 3: So I wonder which side the author fell on. And yeah,
Speaker 3: so you know, of course for there to be a debate,
Speaker 3: there has to be at least two sides. So on
Speaker 3: the other side was a physician from Philadelphia named Philip
Speaker 3: Singh physic who in eighteen twenty eight modified an instrument
Speaker 3: that was normally used to remove the uvula and used
Speaker 3: it as a tonsil guillotine. He wrote, quote, it is
Speaker 3: easy to cut off the whole or any portion that
Speaker 3: maybe of the enlarged tonsil. The operation can be fulfilled
Speaker 3: in a moment of time. The pain is very little
Speaker 3: and the hemorrhage so moderate that it has not required
Speaker 3: any alteration in four cases in which the doctor has
Speaker 3: recently performed it.
Speaker 2: Sorry, I'm also really wondering why they were taking out
Speaker 2: people's uvulas.
Speaker 3: I don't know that part. Yeah, that's like the sneaky, scary,
Speaker 3: terrifying part.
Speaker 2: Yeah, I don't know.
Speaker 3: Okay, hm hm we should do an episode on the uvula.
Speaker 2: We should, I guess now we have to learn.
Speaker 3: About the uvula, quillotine, Usila and this tool that he developed,
Speaker 3: The tonsil atome, was a popular choice for partial tonsil
Speaker 3: ectomies for about eighty years, but some people still use
Speaker 3: the good old fingernail seriously, seriously, I cannot.
Speaker 2: There actual fingers.
Speaker 3: Yes, it's gruesome.
Speaker 2: I yeah. I also just like I'm thinking about tonsils,
Speaker 2: doesn't seem easy.
Speaker 3: No, nothing ever worth doing was easy. I think is
Speaker 3: their mentality.
Speaker 2: Or something something like that.
Speaker 3: But up until the early twentieth century, the removal of
Speaker 3: tonsils via surgery or fingernail was only partial, and physicians
Speaker 3: had noticed that partial removal didn't necessarily alleviate all of
Speaker 3: the symptoms that it was supposed to. Some people had
Speaker 3: regrowth of tissue, others had persistent infections, and so they
Speaker 3: began to try to take more of the tonsils out,
Speaker 3: and they realized that, frankly, the tonsil guillotine or tonsilotome
Speaker 3: was not up to the task. After a series of
Speaker 3: close but no cigar attempts at full removal by surgeons
Speaker 3: throughout the eighteen nineties, English odolaryngologist George Waugh succeeded in
Speaker 3: public about the dissection method he used to completely remove
Speaker 3: the tonsils, and with this ton selectomies, the word first
Speaker 3: used in nineteen oh four, took over modern surgery not
Speaker 3: an exaggeration, not an overstatement. During the first half of
Speaker 3: the twentieth century, from nineteen fifteen to nineteen sixty, ton
Speaker 3: selectomy along with adnoid ectomy were the most frequently performed
Speaker 3: surgeries in the US. Wow, yeah, but like why yeah,
Speaker 3: just because they could? Just because they coulds like everest,
Speaker 3: what about tonsils? Just made people want to rip them
Speaker 3: out of you? And what happened in the mid twentieth
Speaker 3: century to change everyone's mind? Why was this trend reversed?
Speaker 3: I can't wait my nose And if you were hoping
Speaker 3: for like a one line answer, you've come to the
Speaker 3: wrong podcast.
Speaker 2: No one wants a one liner Aaron, No, they don't.
Speaker 3: So to really get at the heart of that question,
Speaker 3: we have to consider not only what people thought tonsils
Speaker 3: did or didn't do, but also how surgery was changing,
Speaker 3: how hospitals were changing, how germ theory was driving concepts
Speaker 3: of infection and disease, and how the theory of evolution
Speaker 3: was shifting the way we viewed form and function in
Speaker 3: our bodies. So, yeah, it's about the tonsils, but it's
Speaker 3: also about so much more than the tonsils. Always I
Speaker 3: love when this happens okay, So let's set the stage
Speaker 3: with the introduction of germ theory in the mid eighteen
Speaker 3: hundreds and then widespread acceptance of it by the end
Speaker 3: of that century, and a full on, you know, war
Speaker 3: on infectious disease launched in the twentieth Many physicians had
Speaker 3: started to look for a causative pathogen for every disease
Speaker 3: that came across their exam table. This before many times,
Speaker 3: but they also began to try to tease apart why pathogens,
Speaker 3: mainly bacteria at this point acted the way they did.
Speaker 3: Why did the collar of bacteria colonize the gut while
Speaker 3: diphtheria was found in the throat at what point? And
Speaker 3: why did pathogenic bacteria invade the bloodstream? And to try
Speaker 3: to answer these questions there arose a concept called focal
Speaker 3: infection theory. Essentially, this idea which was primarily popular in
Speaker 3: the US, especially in the early twentieth century, and not.
Speaker 2: So much elsewhere.
Speaker 3: This idea held that different infections arose in certain areas
Speaker 3: of the body and if not contained, they could spill
Speaker 3: out into the bloodstream and travel to the rest of
Speaker 3: the body from there. So there were different like foxci
Speaker 3: of infection, whether it was your throat, whether it was
Speaker 3: your gut, and that's where that bacteria lived. And then
Speaker 3: if it overflowed, it would that's when it became super deadly,
Speaker 3: went into your plowstam okay. And this seemed to be
Speaker 3: especially popular among American surgeons, since most of the fauxci
Speaker 3: of infection were quote anything that is readily accessible for
Speaker 3: surgery end quote, as one one pathologist joked and consoles
Speaker 3: fit the bill exactly. They were located in the throat,
Speaker 3: which was seen as a major portal of infection along
Speaker 3: with the mouth and nose. They were easily accessible, and
Speaker 3: centuries of successful removal suggested that they weren't missed all
Speaker 3: too much provided you stopped the hemorrhaging. The question of
Speaker 3: whether their removal actually did anything didn't really seem to
Speaker 3: come into play, at least for a while. Personal experience
Speaker 3: from the surgeon was more the gold standard of the
Speaker 3: day than say, like a case control study or statistic.
Speaker 2: Like if they thought it was great, then it was great.
Speaker 3: Kind of thing anecdote leading all right, Like I took
Speaker 3: the tonsils out of this patient that kept getting sore throats,
Speaker 3: and now they don't get sore throats.
Speaker 2: Uh huh, or you just don't see them anymore because
Speaker 2: there's nothing for you to surgerize exactly. Oh okay, I
Speaker 2: mean anyways, you know, it's took a while for statistics
Speaker 2: to catch on.
Speaker 3: Yeah yeah, yeah, yeah, yeah yeah. And of course this didn't.
Speaker 3: This wasn't like wide acceptance, right, This wasn't tonsile ectomies
Speaker 3: for everyone. Surgeons varied in how enthusiastic they were about
Speaker 3: the procedure and how likely they were to recommend it.
Speaker 3: Some thought prophylactic removal was best, like whoa, you get
Speaker 3: to a certain age, get them out of there, get
Speaker 3: those tosses gone. Others were more conservative, recommending removal only
Speaker 3: after multiple infections. But by and large, the predominant belief
Speaker 3: about tonsils was that no one knew exactly what they did,
Speaker 3: what they're purpose was, but they did think that they
Speaker 3: were behind many systemic infections, harboring bacteria that entered the
Speaker 3: throat and then replicated in the tonsils and then were
Speaker 3: released to the rest of the body through the bloodstream.
Speaker 3: So the tonsils were viewed as like this incubator of infection, interesting,
Speaker 3: and so getting rid of them ideal, no big deal.
Speaker 3: At the very minimum, the best thing you could do
Speaker 3: at the maximum. In the nineteen twenties paper by Edwin Place, quote,
Speaker 3: the importance of the tonsils in the acute infections as
Speaker 3: a point of attack and as a portal of entry
Speaker 3: for infections is so much a matter of common experience
Speaker 3: as to require no demonstration here end quote, citation not needed,
Speaker 3: which I find kind of amazing, Like how without much
Speaker 3: supporting evidence or direct investigation looking at what the tonsils
Speaker 3: actually did, there was just like an assumption widespread that
Speaker 3: they were not important.
Speaker 2: I wonder how much of it could have been the
Speaker 2: bias of seeing only the abnormal that you see, right,
Speaker 2: Like if you only see the kids who are coming
Speaker 2: to you because they're tonsils are giant and swollen, and
Speaker 2: they're causing problems, take them out, you're fixing people, But
Speaker 2: you're not seeing all of the people who's not having
Speaker 2: any problems with their tonsils and who are living just fine. Right,
Speaker 2: But it's like you only are seeing these so they're
Speaker 2: only a problem. I don't know, but I don't know,
Speaker 2: I don't know well.
Speaker 3: And one of the things that I was thinking about
Speaker 3: as I read for this episode was how much that
Speaker 3: attitude about like the tonsils not being important might have
Speaker 3: been driven by this idea of vestigial structures. So vestigial
Speaker 3: structures are structures that have remained in a species but
Speaker 3: during evolution lost their primary ancestral function, and so they
Speaker 3: appear not to serve a purpose. I always thought that,
Speaker 3: you know, appendix and tonsils, whatever, we're all lumped together
Speaker 3: under vestigial structures.
Speaker 2: And that's what I grew up.
Speaker 3: Thinking that tonsils were not necessary and that's why people
Speaker 3: removed them, and they're just some remnant of evolution. Okay,
Speaker 3: but let's I want to get into a little bit
Speaker 3: of like the origins of So this concept of vestigial
Speaker 3: structures gained traction, especially since Darwin's On the Origin of
Speaker 3: Species and the Descent of Man in the mid nineteenth century,
Speaker 3: introducing the theory of evolution, and also in Robert Wiedersheim's
Speaker 3: The Structure of Man in eighteen ninety five, where he
Speaker 3: listed dozens of vestigial structures and humans. Oh, tonsils were
Speaker 3: not on Riedersheim's list, but plenty of people believed that
Speaker 3: they didn't have a purpose any longer. So it seems
Speaker 3: plausible to me at least, this is definitely a pet
Speaker 3: hypothesis that the enthusiasm for tonsil ectomies was driven in
Speaker 3: part by embracing the theory of evolution by natural selection,
Speaker 3: where vestigial structures were seen as evidence for evolution. We
Speaker 3: know now, of course, that many structures previously considered vestigial,
Speaker 3: like tonsils and the appendix, aren't actually vestigial. Like They
Speaker 3: still have a function. It might be slightly different than
Speaker 3: its evolutionary origins, but the fact that they have a
Speaker 3: function does not at all refute the existence of evolution,
Speaker 3: which is what many creationists will try to argue that
Speaker 3: there is no such thing as a vestigial structure because
Speaker 3: there are no mistakes, and also we didn't evolve from
Speaker 3: other organisms, so all vestigial structures must have a function.
Speaker 3: I'm not going to get into that whole pan of worms.
Speaker 3: I will link to some papers about the concept of
Speaker 3: vestigial organs, which do exist. They f you're curious and
Speaker 3: want to read more, But I just thought it was
Speaker 3: really interesting sort of this timing of when vestigial organs
Speaker 3: and the theory of evolution was like gaining traction growing
Speaker 3: in popularity. Did that timing help to spur the frequency
Speaker 3: of tonsilectomies.
Speaker 2: That's really interesting. I don't know.
Speaker 3: That's my little pet hypothesis, but if it did, it
Speaker 3: was certainly wasn't the only thing. Throughout the first half
Speaker 3: of the twentieth century, surgery overall had experienced a tremendous shift.
Speaker 3: The combination of anesthesia, which had been around since at
Speaker 3: least the nineteenth century, antibiotics in the nineteen thirties and
Speaker 3: nineteen forties. The growth of hospitals and the formalization of
Speaker 3: medical and surgical training had led to a rapid expansion
Speaker 3: of surgery overall and the development of many specialties within
Speaker 3: surgery and medicine. And what better procedure to practice on
Speaker 3: and earn money on than the minimally invasive, generally low
Speaker 3: risk tonsilectomy. It became a routine operation for so very
Speaker 3: many children. Wow, I couldn't find a ton of numbers,
Speaker 3: but I did read that in between nineteen twenty eight
Speaker 3: and nineteen thirty one, ton selectomies accounted for about one
Speaker 3: third of all surgical operations. In nineteen twenty In New
Speaker 3: York City alone, forty seven thousand tonsilectomies were performed. By
Speaker 3: the mid nineteen hundreds, nearly half of the kids in
Speaker 3: some regions had had their tonsils removed. What and it
Speaker 3: estimated one point five to two million individuals, largely children,
Speaker 3: had their tonsils removed in peak years in the US.
Speaker 3: Wow yeah, yeah.
Speaker 2: Oh gosh, with numbers like that, it's no wonder that
Speaker 2: it's like part of our collective consciousness, right wow.
Speaker 3: And also like how amazing the shift has been. And
Speaker 3: so tons electomies gained traction through parenting books, pediatricians, even
Speaker 3: just word of mouth, and they were hailed as all
Speaker 3: but essential if you wanted to ensure the health of
Speaker 3: your child. But while many surgeons and pediatricians were content
Speaker 3: to accept this as just fact, others had decided to
Speaker 3: apply a little thing called statistics. One of the largest
Speaker 3: and earliest studies comparing kids with and without tonsils with
Speaker 3: upwards of twenty thousand children, found results that were largely
Speaker 3: unsatisfying to ton selectame enthusiasts. It did seem that there
Speaker 3: were some benefits such as reduction and sore throats, cervical adinitis, otitis,
Speaker 3: media scarlet fever, dip theory, rheumatic fever, and heart disease.
Speaker 3: Others found like the opposite trends with some of those,
Speaker 3: but when it came to sinusitis, colds, chicken pox, mumps, measles, tuberculosis, asthma,
Speaker 3: and hay fever, nothing or as another study found higher
Speaker 3: rates in those who had had their tonsils removed. A
Speaker 3: reminder here to take this with a grain of salt,
Speaker 3: considering that it was the nineteen twenties. Follow up was
Speaker 3: patchy at best. You know, statistics were developing, but these
Speaker 3: studies and many others that followed were the first signs
Speaker 3: that maybe ton selectamies weren't like all that they had.
Speaker 2: Promised to be.
Speaker 3: Doubt continued to grow into the nineteen thirties as people
Speaker 3: began to question the justifications that had previously been accepted
Speaker 3: without reservation, like the focal theory of disease, which by
Speaker 3: this time had fallen out of favor. And then there
Speaker 3: was the question of what a diseased tonsil looked like. Tonsils,
Speaker 3: like many other body parts, come in all shapes and sizes,
Speaker 3: and they changed not just like over many years, but
Speaker 3: also they could change day to day absolutely, So what
Speaker 3: looks you know, quote unquote irregular to one surgeon could
Speaker 3: look totally normal to another. Also, based on their personal experience.
Speaker 3: Is there a standard for tonsil size?
Speaker 1: No?
Speaker 3: Nah. Studies like the one I mentioned continued to cast
Speaker 3: doubt on the utility of tonsil ectomies, with the author
Speaker 3: of that big study saying, quote, the desired relationship between
Speaker 3: the tonsils and the various infections in childhood is not
Speaker 3: as clear today as it seemed ten years ago. Statistical
Speaker 3: and controlled clinical studies have obliged us to modify or
Speaker 3: even change our views on this relationship quote.
Speaker 2: The statistics making things less fun for everyone. Just kidding.
Speaker 3: Always, but also science at work. Yeah. On top of
Speaker 3: the whole rationale for tonsilectomies being called into question was
Speaker 3: the finding that many of the procedures had been incomplete,
Speaker 3: with a residual tonsil tissue found in well over half
Speaker 3: of some groups of patients. By the late nineteen thirties,
Speaker 3: a reckoning had truly begun, But for a long time
Speaker 3: that reckoning was more or less confined to the medical literature.
Speaker 2: Huh.
Speaker 3: Pediatricians continued to recommend ton selectomy and adenoidectomy for their patients,
Speaker 3: not just in extreme cases or not just when they
Speaker 3: felt it warranted it. But it was like at the
Speaker 3: drop of the hat, and this continued for decades, and
Speaker 3: parents who had maybe grown up having their own tonsils removed,
Speaker 3: continued to ask for the procedure for their kids even
Speaker 3: long after that. The shift in attitude surrounding tonsilectomy and
Speaker 3: its rise and fall is I think one of the
Speaker 3: clearest examples that I've come across of the time lag
Speaker 3: in scientific research reaching application and general knowledge. Interesting a
Speaker 3: new concept is put forth, like the ton selectomies maybe
Speaker 3: not being as necessary as once thought, it takes a
Speaker 3: while until it's accepted among other researchers in that niche field,
Speaker 3: because they've got to test it, confirm that there's evidence
Speaker 3: to support it, and then it takes even longer to
Speaker 3: sneak its way into application or tech books, and then
Speaker 3: even longer until it reaches the general public. So like,
Speaker 3: if you were a pediatrician trained during the time that
Speaker 3: tonsillectomies were all the rage, and you learned in your
Speaker 3: med school training that hey, if you have a kid
Speaker 3: that has one sore throat, take them out, they're gone,
Speaker 3: take them out prophylactically might as well. Then let's say
Speaker 3: that you go into teaching, you spend the rest of
Speaker 3: your career thirty forty fifty years teaching the next generation
Speaker 3: of pediatricians potentially that this is a routine surgery of childhood,
Speaker 3: and this is a this is a gross generalization, and
Speaker 3: this is like an exaggeration of how things can be
Speaker 3: not really.
Speaker 2: Not actually not hugely too, like happens every day.
Speaker 3: How long does it take for a new generation of
Speaker 3: doctors to unlearn what had been previously accepted knowledge? And
Speaker 3: where is that older physician, that one who's teaching all
Speaker 3: of these new physicians, Where are they going to encounter
Speaker 3: dissenting views without routinely looking through primary literature and without
Speaker 3: training in epidemiology or statistics, how are they going to
Speaker 3: assess how legitimate the conclusions of a study are?
Speaker 2: Oh, eron. This is one of my favorite things because
Speaker 2: it's something I think about literally all the time at
Speaker 2: my other job too.
Speaker 3: You know, there is such a gap not just in
Speaker 3: primary research and sort of getting that to non specialty
Speaker 3: fields or like feels outside of that specialty, But then
Speaker 3: how long does that information then take to reach the
Speaker 3: general public.
Speaker 2: It's so long aerin like in the nineteen twenties, it
Speaker 2: was probably even longer, and even today with the Internet,
Speaker 2: it's still long.
Speaker 3: Oh, it's still so it's so long. And in the
Speaker 3: case of tonsils, we have like decades, decades. It began
Speaker 3: to be realized in the nineteen twenties and then when
Speaker 3: did the trends really change. I would say nineteen sixties
Speaker 3: more widespread with in the medical community, and then nineteen
Speaker 3: seventies and eighties is when like the decline had really begun.
Speaker 2: Wow.
Speaker 3: Yeah, And there were like still articles about the benefits
Speaker 3: of ton selectames in parenting books and not all the time,
Speaker 3: like sometimes there was you know, urging caution with ton
Speaker 3: selectamy and recommended removal in only extreme cases. And this
Speaker 3: was not like you know, we're not talking about and
Speaker 3: then we turned a corner and then you know, immediate
Speaker 3: sharp differences in this, like the conversation continued to exist
Speaker 3: around ton selectomies. So there was more negative press in
Speaker 3: the nineteen forties and nineteen fifties, but like parents really
Speaker 3: wanted their kids to have ton selectomies, and it wasn't
Speaker 3: just parents recommending it, right, it was pediatricians who had
Speaker 3: that's what they had learned to do. That and the
Speaker 3: growth of voluntary health insurance plans post World War Two,
Speaker 3: which is likely why we see higher rates of ton
Speaker 3: selectomy during that time period in children from middle and
Speaker 3: upper class families i e. Those who could afford to
Speaker 3: pay for an elective surgery cohered to those without insurance.
Speaker 3: That's sort of an interesting little tidbit, sure is. And so,
Speaker 3: like I said, nineteen sixties, doubt became more you know,
Speaker 3: on the loud speaker. Nineteen seventies and eighties rates had
Speaker 3: really declined. And part of this decline, I have no
Speaker 3: doubt was the rise in antibiotic use, which could treat
Speaker 3: many infections commonly associated with tonsils, and the growing specialization
Speaker 3: in pediatrics where pediatricians rarely received surgical training, and so
Speaker 3: we're just less exposed to tons electomies overall. That's at
Speaker 3: least according to one paper that suggested that in nineteen
Speaker 3: sixty five in the US, one million, two hundred and
Speaker 3: fifteen thousand tonsilectomies were performed. Just a couple of decades later,
Speaker 3: in nineteen eighty six, that number had fallen to two
Speaker 3: hundred and eighty one thousand, and then it rose again
Speaker 3: in nineteen ninety six to three hundred and eighty three thousand.
Speaker 3: But like you know, that could be a number of
Speaker 3: different factors. And I should point out that the US,
Speaker 3: where all of these numbers come from, was the leading
Speaker 3: ton selectamy country. The procedure was also popular in England,
Speaker 3: but not as popular and it fell out of favor sooner.
Speaker 3: This re examination of the necessity of ton selectomies allowed
Speaker 3: for more careful consideration of when they should be performed, because,
Speaker 3: as you talked about, as our first hand demonstrates, there
Speaker 3: are still many cases where it is essential. But the
Speaker 3: history of ton selectamies provides but I think is one
Speaker 3: of the most fascinating glimpses into the inertia of science
Speaker 3: tific knowledge, where it can take literally generations to incorporate
Speaker 3: new findings into practice, and then generations more into general knowledge.
Speaker 3: And that's the history of tonsils.
Speaker 2: I love that here.
Speaker 3: This is one of my favorite ones to do recently.
Speaker 2: I think I loved listening to it.
Speaker 3: So, Aarin, tell me what's going on with tonsils today?
Speaker 3: We're still doing them, but like under what circumstances?
Speaker 2: Yeah, okay, let me tell you right after this break. Honestly,
Speaker 2: it was very difficult, pretty much impossible to get any
Speaker 2: kind of data on like incidence, prevalence of tonsilitis or
Speaker 2: recurrent tonsilitis or pharonitis. Like, come on, it's we can't
Speaker 2: do that. It's too common. It's so common. It's everyone
Speaker 2: everywhere all the time. I had a start throat yesterday. Okay,
Speaker 2: it's nearly always self limited. It's not an infection that
Speaker 2: we can track. But that doesn't mean I have no
Speaker 2: data for you. I found a very interesting paper out
Speaker 2: of the UK. It's a few years old now, but
Speaker 2: it was very interesting. What it looked at, specifically was
Speaker 2: the incidence of ton selectame and the proportion of these
Speaker 2: ton selectames that were based on what they considered to
Speaker 2: be truly evidence based criteria versus the proportion of ton
Speaker 2: selectames that were not fitting with evidence based criteria m.
Speaker 2: This was from two thousand and five to twenty sixteen,
Speaker 2: so like a little old, but like not super old,
Speaker 2: so like current enough. What's fascinating about this study is
Speaker 2: that what they found overall, in conclusion, is that in
Speaker 2: the UK, in the population that they looked at, it
Speaker 2: wasn't every kid in the UK, but it was several
Speaker 2: hundred thousand kids, about four in one thousand children. And
Speaker 2: this again was all in children, four in one thousand
Speaker 2: met evidence based criteria for ton selectomy. So first of all,
Speaker 2: we can talk about what does that actually look like
Speaker 2: like what today is considered guideline approval evidence based for
Speaker 2: ton selectomy.
Speaker 3: Yeah.
Speaker 2: The major criteria is what are called the Paradise criteria.
Speaker 2: I don't know why, don't ask why, and this is
Speaker 2: pretty like hardcore criteria. It is seven documented episodes of
Speaker 2: severe sore throat or tonsilitis in one single year. Seven
Speaker 2: And part of it is that this is documented as
Speaker 2: severe sore throat, meaning that a sore throat that's not
Speaker 2: bad where someone doesn't go to the doctor wouldn't count
Speaker 2: because those episodes are considered to be less severe. Could
Speaker 2: you argue about access to healthcare, et cetera. Yes, definitely.
Speaker 2: This was in the UK, they at least have a
Speaker 2: national healthcare system. Okay. So it's seven episodes of severe
Speaker 2: sore throat in one year, or five per year for
Speaker 2: two years in a row, or three per year for
Speaker 2: three years in a row. Okay. Those are the most
Speaker 2: common criteria, the Paradise criteria. The other criteria that they
Speaker 2: considered in this paper to be evidence based was a
Speaker 2: tonsillar tumor, which makes sense. Yep, and a condition called
Speaker 2: PFA PA, which stands for periodic fever, apthys stomatitis, pharyngitis,
Speaker 2: and adinitis.
Speaker 3: That's a lot of itises.
Speaker 2: It's a lot of itises. And what this actually is
Speaker 2: is like a genetic condition that results in these periodic fevers,
Speaker 2: these ulcers in the mouth and a sore throat and
Speaker 2: swollen tonsils, adenoids and lymph nodes and things like that. Okay,
Speaker 2: it's not super common. It's a genetic disorder. We could
Speaker 2: probably do a whole episode on it. But those are
Speaker 2: the three things that they considered as evidence based criteria
Speaker 2: for tonsillectomy. Four in a thousand kids in this study
Speaker 2: met criteria like that was the overall prevalence, but less
Speaker 2: than one in seven of those kids had a ton
Speaker 2: select to me. Between two to three kids per one thousand,
Speaker 2: uh huh each year had a ton select to me,
Speaker 2: but less than one in eight of the kids who
Speaker 2: had ton select tom actually had an evidence based indication.
Speaker 2: WHOA Yeah, So, like lots of kids met criteria for
Speaker 2: ton select tom for what they considered evidence based criteria
Speaker 2: for ton selectomy, did not have a ton selectomy, and
Speaker 2: many many more kids did not meet criteria for ton
Speaker 2: select TOM and yet had a ton select TOM. So
Speaker 2: their overall conclusion was that of the thirty seven thousand
Speaker 2: ton selectimes that were performed in the UK in this
Speaker 2: time in this population each year, thirty two thousand of
Speaker 2: them were quote unnecessary.
Speaker 3: What is going on?
Speaker 2: Okay, here's part of what's going on. A large proportion
Speaker 2: of the kids who underwent ton SELECTAM in this study
Speaker 2: had one, two or three or sometimes four or five
Speaker 2: episodes of tonsillitis, so they had severe sore throat. They
Speaker 2: had evidence of tonsil infection, but not enough per year
Speaker 2: to meet this evidence based criteria. Okay, that's a big one.
Speaker 2: The other one is sleep apnea or obstructive sleep disordered breathing.
Speaker 3: Which is not on the list of recommended whatever.
Speaker 2: Criteria in this paper in the UK, it's not considered
Speaker 2: an evidence based indication. But the number of kids who
Speaker 2: have been having and who have been recommended for ton
Speaker 2: SELECTAM and really adenoidectomy especially and sometimes not both, sometimes
Speaker 2: just adenoid ectomy who were referred for ton selectames over
Speaker 2: that time period, or obstructive sleep disordered breathing or obstructive
Speaker 2: sleep apnea increased over this time period, and It's really
Speaker 2: interesting because in this paper in the UK it was
Speaker 2: not considered an evidence based indication. But what they did
Speaker 2: mention is that there is data that shows that adenoidectomy,
Speaker 2: specifically so removal of just that pharyngeal tonsil does reduce
Speaker 2: snoring and can show short term improvements in the quality
Speaker 2: of life on a few different metrics for kids ages
Speaker 2: five to nine who have obstructive sleep disordered breathing or
Speaker 2: obstructive sleep apnea and who undergo adenoidectomy. But there isn't
Speaker 2: a lot of long term data on its effectiveness, and
Speaker 2: there is not necessarily data that it improves all possible
Speaker 2: outcomes or all possible complications associated with sleep disc breathing. Okay,
Speaker 2: so according to this paper, that was not enough evidence
Speaker 2: to consider it an evidence based indication. Does that make sense? Yes.
Speaker 2: It doesn't necessarily mean there's no utility in it or
Speaker 2: that it can't be beneficial. It just means, according to
Speaker 2: this there wasn't enough data. Yeah. So I think that
Speaker 2: that's an interesting part because part of the story of
Speaker 2: the number of ton selectamies is like how bad does
Speaker 2: it have to be to consider ton selectam evidence based
Speaker 2: versus not right? Like what outcomes are we looking at?
Speaker 2: How much data do we have to prove that?
Speaker 3: Like?
Speaker 2: What what are we going off of? So that was
Speaker 2: in the UK. What's interesting is that that paper highlighted
Speaker 2: that the rates of ton selectomy very really widely across
Speaker 2: the globe. That paper specifically just mentioned that rates in Belgium,
Speaker 2: Finland and Norway are about twice as high as in
Speaker 2: the UK, whereas Spain, Italy and Poland significantly lower than
Speaker 2: the UK. And then in the US rates tend to
Speaker 2: be about three times as high as in the UK.
Speaker 2: So let's think about the US for a quick moment here. Yeah,
Speaker 2: love to According to the American Academy of odal Aaryngology
Speaker 2: and had an ex surgery foundation, and this was data
Speaker 2: that was in a twenty nineteen update on their guidelines,
Speaker 2: but I think the data is older than that. There
Speaker 2: are about two hundred and eighty nine thousand ton selectomies
Speaker 2: performed each year just on kids under age fifteen. It's
Speaker 2: really hard to get data on ton selectomy in adults
Speaker 2: because it's a much much less common procedure. Which what's
Speaker 2: interesting about that number two hundred and eighty nine thousand
Speaker 2: is that aarin you said that was the number at
Speaker 2: the end of the eighties, so like, yeah, it just
Speaker 2: hasn't really changed, which I find really interesting.
Speaker 3: Well, that's what I was wondering about when you were
Speaker 3: talking about about the criteria that recommend removal or whatever.
Speaker 3: How when were those criteria instituted? How often do we
Speaker 3: revisit criteria ADA or takes them off whatever, Like it's
Speaker 3: just all part of it.
Speaker 2: The most recent update that I could find was twenty nineteen,
Speaker 2: but those had been updated again in twenty eleven, and
Speaker 2: so it's not that infrequent that this society seems to
Speaker 2: be updating their guidelines. And what's interesting about the American
Speaker 2: Academy of Odalaryngologies guidelines is that obstructive sleep disordered breathing
Speaker 2: is an indication for which they do recommend I don't adectomy,
Speaker 2: but they also say that the evidence is not as
Speaker 2: strong for this indication as it is for those paradise
Speaker 2: criteria indication really and the newest guidelines have a strong recommendation.
Speaker 2: So like, whenever you look at guidelines, it's always like
Speaker 2: low quality, moderate quality, high couitquality in terms of like
Speaker 2: the evidence behind it, And then what is the recommendation.
Speaker 2: Is it like a think about it or like a
Speaker 2: we kind of recommend it, or we strongly recommend it.
Speaker 2: That's like how guidelines are worded. So they updated their
Speaker 2: guidelines to strongly recommend holding off watchful waiting unless a
Speaker 2: kid has had at least seven unless a kid meets
Speaker 2: these criteria, essentially the paradise criteria. So it seems like
Speaker 2: the guidelines are really in terms of recurrent infections moving
Speaker 2: more towards pause, wait, treat with antibiotics. Let's really wait
Speaker 2: and see if this kid truly needs a tonsilectomy. But
Speaker 2: in the case of sleep disordered breathing, maybe the numbers
Speaker 2: are going up as we get more evidence for it. Yeah, Okay,
Speaker 2: at this point, we still don't have a ton of
Speaker 2: evidence for it, especially in the long term, but there
Speaker 2: is evidence for short term improvements in sleep outcomes as
Speaker 2: well as behavioral parameters like school performance and things like that,
Speaker 2: because not being able to sleep affects a lot of
Speaker 2: your life. Yeah, or not being able to breathe while
Speaker 2: you're asleep, I should read I mean yeah. So that's
Speaker 2: kind of where we stand with tonsilitis and tonsulid ectomies
Speaker 2: and when it comes to what I wanted to talk
Speaker 2: about with like the future of tonsils. I really didn't
Speaker 2: know where I wanted to go. There seemed like so
Speaker 2: many possibilities, but luckily I found this fascinating paper took
Speaker 2: me to a place I never expected. In twenty twenty one,
Speaker 2: you're ready for this airin it's pretty exciting.
Speaker 3: I don't know, I'd better be.
Speaker 2: In twenty twenty one, there was a paper published in
Speaker 2: Nature Medicine by someone named wagar at All. I think
Speaker 2: sorry if I pronounce it wrong. Here's what they did.
Speaker 2: Arin They took tonsil tissue just like tissue from discarded
Speaker 2: tonsils after a tonsulidectomy, I presume, and grew it in
Speaker 2: cell culture cool. And what this tonsil tissue did was
Speaker 2: reaggregated itself into little organoids, little baby tonsils on your
Speaker 2: little cell culture plate. And then what they did was
Speaker 2: they exposed these tiny baby little tonsils to things like,
Speaker 2: for example, a live attenuated flu vaccine, which is something
Speaker 2: that we know a lot about how these flu vaccines
Speaker 2: work in our bodies and what kind of an immune
Speaker 2: response it generates. And they did this to study the
Speaker 2: immune response in these little baby organoid tonsils. On a
Speaker 2: cell culture plate. What they were doing is creating a
Speaker 2: new type of model system to be able to study
Speaker 2: the human immune response and specifically our antibody mediated immune response,
Speaker 2: which again our tonsils are particularly good at, especially for
Speaker 2: things like respiratory infections.
Speaker 3: We have underestimated and underappreciated tonsils for far too long.
Speaker 2: I agree.
Speaker 3: That is so cool.
Speaker 2: It's so cool. They went beyond They also tested it
Speaker 2: with like SARS CoV two infection and vaccines, And then
Speaker 2: there was another study that I'll also link to that
Speaker 2: like just really specifically looked at using this as a
Speaker 2: model for SARS infection, for SARS CoV two infection. It
Speaker 2: is a fascinating, amazing tool to be able to study
Speaker 2: things like future vaccine development, to be able to test
Speaker 2: things and see what kind of an immune response is
Speaker 2: generated in a very realistic human model rather than just
Speaker 2: animal models which are far from perfect because animal immune
Speaker 2: systems are not the same as are really cool, really exciting.
Speaker 2: I have a couple fun papers for people to read.
Speaker 3: Tonsils amazing, I know.
Speaker 2: If people want to read more, Boy, have we got
Speaker 2: something for you?
Speaker 3: Oh yeah, so we got lots of sources. I'm going
Speaker 3: to shout out two in particular, so I already shouted
Speaker 3: out that one by McNeil from nineteen sixty A History
Speaker 3: of ton Selectomy to millennia of trauma, hemorrhage and Controversy.
Speaker 3: And then the other one that I want to shout out,
Speaker 3: although I do have more, is by Grobe from two
Speaker 3: thousand and seven, The Rise and Decline of ton selectam
Speaker 3: in twentieth Century America. Fascinating.
Speaker 2: I have a few tonsil papers that I want to
Speaker 2: shout out. Three of them, one by Cooper at All
Speaker 2: Mucosa Associated Lymphoid Tissues is the title, and it was
Speaker 2: again about all malt and it was really a great read.
Speaker 2: Bathala at All from twin thirteen was a review on
Speaker 2: the mechanism of sore throat and tonsilitis super fascinating and
Speaker 2: really gets at why ice cream? Why ice cream? Cold
Speaker 2: inhibits the release of a lot of these cytokinds, and
Speaker 2: it can also inhibit the actual pain receptors. So like
Speaker 2: cold is what you want in your throat when it hurts,
Speaker 2: Oh my gosh, there's more of that. I love about it, okay,
Speaker 2: And then another one by A Ramboula at All from
Speaker 2: twenty twenty one that was anatomy and physiology of the
Speaker 2: palatine tonsils, adenoids and lingual tonsils. And then of course
Speaker 2: I have links to those recent papers about tonsil organoids
Speaker 2: and using them to study our immune response. You can
Speaker 2: find the list of sources from this episode and every
Speaker 2: single one of our episodes on our website under the
Speaker 2: episodes tab.
Speaker 3: Thank you so much again, Aarin, the third erin of
Speaker 3: the episode love It, for sharing your story with us.
Speaker 3: We really appreciate it.
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